INTEGRATIVE HEALTHCARE GROUP & REHABILITATION CENTER

932 Ward Avenue, 6th floor, Honolulu, Hawaii 96814  Phone (808)535-5555 Fax (808)535-5556

Please provide the following information completely, to the best of your ability, so that we can provide you with the
best service possible in all aspects of your treatment at our facility. Thank you.

PERSONAL INFORMATION

Last Name
SCOTT M.I.
A First Name
LAWRENCE II _________
330 SARATOGA RD UNIT 8166 HONOLULU HI 96830
Address ___________________________________ City _________________
Address______________________________________________ State _________
City_________________ Zip Code ______________
State_________ Zip Code_ __________

Home# Cell # 808-384-8280 Email:

las808@outlook.com __________

Gender Male Female Date of Birth

12/13/1990 Marital Status:
SINGLE 381-13-2940
SS # _____________________

Occupation
DISABLED Employer _______________________________________________________
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EMERGENCY CONTACT INFORMATION:

Name:
LAWRENCE SCOTT Phone #:
808-372-7023_Relationship: FATHER ______

Name: AJ TORRES
FRIEND
Phone #:808-779-5500 _Relationship: ________________________________

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INSURANCE INFORMATION

Primary Ins.
QUEST OHANA HEALTH PLAN Secondary Ins. _______

Insured Name:
LAWRENCE A SCOTT II Insured Name: ____________________________________________

Relationship to Insured: ___DOB: _________ Relationship to Insured: ________ DOB: _________

Subscriber # Subscriber #________________________________________________

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STRAUB HOSPITAL EMERGENCY ROOM
Referred By: _________________________________________________ Primary Dr: NONE
How did you hear about us: ______________________________________________________________________________________
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 W/C Injury  NF Injury  TPL Injury Insurance _____

Date of Injury Claim # ________

Adjuster Phone # Ext. _________

Attorney Name Phone # _______

I understand and agree that health and accident insurance policies are in agreement between an insurance carrier and myself. I authorize
payment from my insurance carrier to be sent directly to this office with the understanding that all monies will be credited to my account
upon receipt. However, I clearly understand and agree that monies rendered to me are charged directly to me and that I am personally
responsible for payment. Furthermore, if my insurance carrier denies payment of my services, or I exceed maximum allowable benefits, I
agree to pay all outstanding bills. I also understand that if I suspend or terminate my care that fees for professional services rendered to me will
be immediately due and payable. In the event of default I promise to pay legal interest on the indebtedness together with any collection cost
and reasonable attorney fees as may be required to effect collection.
There will be a $25 processing fee for all returned checks.

Signature Date
4/16/2022
 INTEGRATIVE HEALTHCARE GROUP & REHABILITATION CENTER

932 Ward Avenue, 6th floor, Honolulu, Hawaii 96814  Phone (808)535-5555 Fax (808)535-5556

Dear Patient,

We would like to thank you for your confidence in and support of our clinic, and the emerging field of
integrative healthcare. It is your support and commitment that has allowed us to flourish and to provide you
and our community with the highest quality integrative healthcare. We hope that Manakai 0 Malama will
continue to be your partner in health for years to come.

We are always looking at ways to improve our performance and we welcome your
feedback as a way to direct our efforts. Please direct any feedback you have to our
customer service email: customerservice@manakaiomalama.com

We would like to take this opportunity to review our cancellation policy. Your visits are a crucial part of your
treatment plan and recovery process. Your individual treatment plan is also designed for your maximum
benefit. By missing an appointment or by arriving late and reducing your treatment time you may interrupt the
healing process. We do understand that the unexpected happens, and that injury or illness may cause
forgetfulness, 'bad days,' etc. To come in for treatment may be the best antidote for those ‘bad days’. We ask
for your consideration of the following simple guidelines:

Late Arrival - Please call if you expect to arrive more than 5 minutes late for an
appointment. Our practitioners will do their best to accommodate you if they can do
so without disrupting another patients' care. If you are more than 10 minutes late your
appointment may be rescheduled and you may be charged a missed appointment fee.
LS
Initial_______

Appointment Cancellations - If you need to cancel an appointment, please give us 48

hours’ notice. This allows us to reassign that time slot and reschedule your treatment as
needed. Appointments rescheduled within 48 hours may be subject to a reschedule fee
LS
of $25. Initial______

Missed Appointments - If you miss 3 appointments without cause or notification we do

reserve the right to suspend your treatment. If you do not show up for a scheduled
appointment you may be charged a $50 missed appointment fee for the visit.
LS
Initial ______

By abiding by these guidelines you can help us maximize our efficiency and your service delivery. On our part,
we will continue to make every effort to stay on schedule, to ensure wait times are short, and to offer you the
highest quality healthcare.

Mahalo from all of us at Manakai 'O Malama.

I have read the above and agree to make every effort to abide by these
guidelines in the future.

Patient Name:
LAWRENCE A SCOTT II
Patient signature: Date: 4/16/2022
 HAWAII PRIVACY OF HEALTH CARE INFORMATION LAW

INTEGRATIVE HEALTHCARE GROUP & R EHABILITATION C ENTER

In accordance with the American Medical Association Code of Ethics, we believe that the patient-physician relationship is
based on trust and confidentiality of communication. The free and uninhibited disclosures of personal information within this
relationship are the cornerstone of good medical care.
The privacy of your medical records is of the utmost importance to our staff and us. We have therefore taken measures to
ensure that your medical records receive the highest level of confidentiality and security. This office adheres to the following
procedures to ensure protection of your private medical records.

• Our office staff has received education and training regarding the use and handling of patients
protected health information.
• Your records are secured in this office.
• Access to office keys is limited to our doctors, staff, and bonded cleaning crew.
• Access to electronic information is only released as required or permitted by state of federal law.

AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION

LAWRENCE A SCOTT II , hereby authorize Manakai 0 Malama Integrative

(Patient, parent or legal guardian)

Healthcare Group to disclose health information, including copies or summaries of medical records for
LAWRENCE A SCOTT II to:
(Name of patient)

a. Any health insurance plan or company that provides insurance coverage for the purpose of payment of charges,
b. Any insurance company that provides liability insurance coverage for providers of Manakai O
Malama for the purpose of evaluating the treatment rendered or
c. Any health care provider that has referred the patient to this office for care, for the purposes of
coordination of medical care.

This authorization shall cover the period of time from my first visit to my last visit. I understand that I can revoke this
authorization at any time. This authorization shall end two years after the date of my last visit.

4/16/2022
Signature Date

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MEDICAL INFORMATION RELEASE

I hereby authorize the staff of Manakai O Malama to release my confidential medical information to the following:
AJ TORRES FRIEND 808-779-5500
Name Relationship Phone#_ _________________

4/16/2022
Signature Date
 Manakai O Malama Integrative Healthcare Group and Rehabilitation Center
932 Ward Avenue, 6th floor, Honolulu, Hawaii 96814 Phone (808)535-5555 Fax (808)535-5556

Pre-appointment Questionnaire
What is the main reason for your appointment today?

Is this due to (check one):  Auto Accident  Work Injury  Other Cause  Unknown  Illness

Are your symptoms:  Improving  Getting Worse  Staying the Same  Come and Goes

Activities that aggravate:  Standing  Walking  Sitting  Lying  Bending  Lifting  Twisting
 Coughing ____________

Have you seen another health care provider for this problem?  No  Yes ___________________
When: _________________________________
4/15/2022 Diagnosis: ___________________________________________
Closed fracture of left side of mandibular body

Is there anything you would like to work on to improve your health?

Please respond if you have one of the following conditions:

High Cholesterol Problems with medication(s)?  No  Yes  N/A

Diabetes Problems with medication(s)?  No  Yes  N/A

Most recent home glucose readings:

High Blood Pressure Problems with medication(s)?  No  Yes  N/A

Most recent home blood pressure readings:

Depression Problems with medication(s)?  No  Yes  N/A

Any suicidal thoughts?  No  Yes  N/A

Have you been to the emergency room, hospital or any other provider since your last visit?
If yes, please explain:

Visited ER October 5, 2020 - For Facial Pain - Mandible Xray had been done. Dr. David H Messer III
found nothing wrong.

Visited ER April 15, 2022 - For Facial Pain - CT had been done. Dr. Dana Watanabe instructed to
followup with a PCP to get a referral for a surgeon to repair my broken jaw.

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 Manakai O Malama Integrative Healthcare Group and Rehabilitation Center
932 Ward Avenue, 6th floor, Honolulu, Hawaii 96814 Phone (808)535-5555 Fax (808)535-5556

Have you been diagnosed with any of the following since your last visit?
If yes, please check:

 Cardiac Murmurs  Abnormal EKG  Sleep Apnea  Diabetes

 Hypertension  Angina Pectoris  Coronary Artery Disease  Mitral Valve disorder

 Tricuspid valve disorder  Pulmonary valve disorder  Atrial-Fib  Atrial-Flutter

 Heart Failure  Cardiomegaly

Are you experiencing any of the following?

 Fever  Chills  Headache  Runny nose

 Weight loss/gain  Sleep disturbance*  Loss of Appetite  Sore Throat

 Malaise/Fatigue*  Excessive thirst  Eye pain  Eye Redness

 Double vision  Vision Loss  Blurred Vision  Ear Pain

 Hearing loss  Ear Drainage  Swallowing pain  Chest Pain*

 Palpitations*  Poor Circulation  Swelling/Edema  Pain in Limb *

 Shortness of breath  Cough  Breathing discomfort  Blood in sputum

 Wheezing  Abdominal Pain  Nausea/ Vomiting  Heartburn

 Bloating  Black/Bloody stool  Loose stool  Constipation

 Pain w/ urination  Difficulty urinating  Blood in urine  Frequent/Urgent

urination

 Impotence  Irregular menses  Neck pain/stiffness  Back pain

 Muscle aches  Swollen joints  Muscle Stiffness  Joint pain

 Bruising  Muscle weakness  Rash  Boils

 Lesions/Moles  Changing mole(s)  Sun Sensitivity  Tingling

 Poor balance  Falling  Numbness  Fainting

 Heat/cold  Speech Difficulty  Weakness  Depression

Intolerance

 Anxiety  Fear  Loss of Interest  Suicidal Thoughts

Lifestyle
Alcohol

How often do you have a drink containing alcohol?

 Never  Monthly or less  2-4 times per month  2-3 times per week
 4 or more times per week

How often do you have six or more drinks on one occasion?

 Never  Less than monthly  Monthly  Weekly  Daily or almost daily

5
 Manakai O Malama Integrative Healthcare Group and Rehabilitation Center
932 Ward Avenue, 6th floor, Honolulu, Hawaii 96814 Phone (808)535-5555 Fax (808)535-5556

Caffeine

Do you consume any caffeine?  No  Yes: How often? How much?

Exercise

Do you exercise?  No  Yes: How often? How long?

Smoking

Do you smoke?  No  Yes: How often? How much?

Birth control

Do you use any form of birth control?  No  Yes: What method?

Medication adherence

Do you have trouble taking any of your medications?  No  Yes: Describe.

Are there any changes to your family medical history? For example, if a family member has
received a new diagnosis, we can update your family history to reflect any changes since your last
visit.

N/A

Have you recently developed an allergy to any of your medications? If yes, please describe
below.

N/A

Do you have any end-of-life care plans or preferences? If yes, please bring a copy of relevant
documents to your upcoming visit (e.g., your advance directive, power of attorney and health care
proxy). If not, would you like to discuss your preferences?

N/A

6
 Manakai O Malama Integrative Healthcare Group and Rehabilitation Center
932 Ward Avenue, 6th floor, Honolulu, Hawaii 96814 Phone (808)535-5555 Fax (808)535-5556

Disease Prevention Screening:

Sleep Apnea

Has anyone told you that you snore loudly or stop breathing when asleep?  No  Snoring loudly (heard
from another room)  Stop Breathing

Skin Cancer

When did you last have a full-body skin cancer check by a medical professional?  I don’t know
 Month/Year___________

Colon Cancer- Adults over 50

Have you had a colonoscopy or other colon cancer screening?  No  Yes: When?

Women

When was your last PAP smear?  I don’t know  Month/Year___________

Women Over 40

Have you had a mammogram?  No  Month/Year___________

Women Over 65

Have you had a bone density test?  No  Month/Year___________

Diabetes Management:
When did you last have your diabetic bloodwork done?  I don’t know  Month/Year___________
When did you last visit your eye doctor?  Never  I don’t know  Month/Year___________
When did you last visit your podiatrist?  Never  I don’t know  Month/Year___________

Do you have any other concerns? If yes, please describe below.